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Marketing e-cigarettes to kids has created an “epidemic” in US, says FDA chief

BMJ 2018; 362 doi: https://doi.org/10.1136/bmj.k3900 (Published 13 September 2018) Cite this as: BMJ 2018;362:k3900

Observations

Start-up e-cigarette brand aims to “improve smokers’ lives”

Re: Marketing e-cigarettes to kids has created an “epidemic” in US, says FDA chief

The article by Roehr (1), unfortunately, does not discuss several crucial issues relating to this development.

Firstly, Commissioner Gottlieb’s remarkably candid explanation (2) identified potentially questionable marketing tactics from some manufactures, commenting:

“There’s some historical advertising that I’ve seen, especially on social media, that gives me pause as to how earnest some of these companies were in making sure that kids didn’t use their products”

Examples of such questionable advertising is available on the Stanford University website (3), and is part of an ongoing investigation, not only by the FDA, but also by the Attorney General of Massachusetts (4, 5), who has challenged “Look at these pictures closely, and tell me whether or not you think this is a company that is there marketing to and looking to directly appeal to young people,” in general, and not specifically adult smokers.

Furthermore, very recent data (6) reveals that new generation e-cigarettes like JUUL and other “pods” produce a very similar, highly efficient delivery of nicotine to the user to that produced by a conventional cigarette. As the authors articulate:

“The levels of nicotine inhaled and absorbed by these pod users were alarmingly high,” . . . “it’s critically important that users, parents, clinicians, public-health advocates and regulatory bodies be informed about how Juul and similar devices work and how they impact the body, as our results show that the risk for long-term product use and nicotine addiction is dangerously high” (7)

Previous data from March 2018 revealed, in children using e-cigarettes, raised levels of several carcinogens and toxins (8). Although the authors acknowledged that vaping is less hazardous than smoking, they highlighted that, due to exposure to these harmful substances, “Messaging to teenagers should include warnings about the potential risk from toxic exposure to carcinogenic compounds generated by these products.”

If, as suggested, the already raised levels of experimentation with e-cigarettes in the U.S. by youth has rapidly and significantly increased (perhaps by 75%, if reports are proved correct), it would be the case that substantial numbers of non-smoking children are now vaping, and using, at least potentially, electronic nicotine delivery devices that are as addictive as conventional cigarettes. Moreover, in the words of the comprehensive National Academies of Sciences Engineering and Medicines there “conclusive evidence that in addition to nicotine, most e-cigarette products contain and emit numerous potentially toxic substances” (9). In terms of the numbers involved, Gottlieb notably states that:

“We have good reason to draw this conclusion based on the trends and data that we’ve seen, some of which is still preliminary and will be finalized in the coming months and presented publicly.”

Presumably, these are at least some of the factors that have prompted Gottlieb to produce such a notably candid and detailed statement, coming from a Commissioner who acknowledges that, last year, he was acting reasonably, so as to allow industry enough time to prepare for new regulations. However, he commented further:

“I’ve been warning the e-cigarette industry for more than a year that they needed to do much more to stem the youth trends. In my view, they treated these issues like a public relations challenge rather than seriously considering their legal obligations, the public health mandate, and the existential threat to these products. And the risks mounted.”

Views here are my own, and not necessarily those of my employer.

1) Roehr, R. Marketing e-cigarettes to kids has created an “epidemic” in US, says FDA chief. BMJ 2018;362:k3900 doi: 10.1136/bmj.k3900 (Published 13 September 2018)
2) The increased nicotine delivery efficiency of new pod devices like JUUL has recently identified
3) https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm620185.htm
4) http://tobacco.stanford.edu/tobacco_main/images_ecigs.php?token2=fm_ecig...
5) https://www.mass.gov/news/ag-healey-announces-investigation-into-juul-ot...
6) https://www.theverge.com/2018/7/24/17608136/juul-investigation-electroni...
7) Goniewicz, Maciej Lukasz, et al. "High exposure to nicotine among adolescents who use Juul and other vape pod systems (‘pods’)." Tobacco Control (2018): tobaccocontrol-2018.
8) https://www.roswellpark.org/media/news/adolescent-users-juul-other-e-cig...
9) Rubinstein, Mark L., et al. "Adolescent exposure to toxic volatile organic chemicals from e-cigarettes." Pediatrics 141.4 (2018): e20173557.
10) https://www.nap.edu/resource/24952/012318ecigaretteConclusionsbyOutcome.pdf

Competing interests: No competing interests

14 September 2018
David W Bareham
Specialist Respiratory Physiotherapist
Chartered Society of Physiotherapy
Lincolnshire Community Health Services, Louth County Hospital, High Holme Road, Louth, Lincolnshire, LN11 0EU